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Aucun titre de diapositive

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    Aucun titre de diapositive Aucun titre de diapositive Presentation Transcript

    • Patient Case Discussion Advanced NSCLC Robert Pirker Medical University of Vienna ESMO International Symposium on Chest Tumors Geneva, 30.3.-1.4.2007
    • Case Discussion Advanced NSCLC
      • A 62-year old man
      • with symptoms of brain metastasis
      • and a lung tumor
    • Case Discussion Advanced NSCLC
      • 62-year old male
      • Smoker ( ~4 0 pack years)
      • No history of serious illnesses, no weight loss
      • Developed severe nausea plus headache in Feb 2001; collapsed on Feb 27, 2001
      • Admission to hospital
    • Case Discussion Advanced NSCLC
      • 178 cm, 82 kg, ECOG-1
      • Heart & lung normal, RR 140/80, 80/min
      • Liver & spleen normal
      • No enlarged lymph nodes
      • No edema
      • No signs of neurological deficits
    • Case Discussion Advanced NSCLC
      • MRI of the brain: Lesion ( ~ 2 cm) fronto-basal on the right site plus edema
    • Case Discussion Advanced NSCLC
      • MRI of the brain: Lesion ( ~ 2 cm) fronto-basal on the right site plus edema
      • Chest X-ray: Suspicion of tumor in left lung
      • CT Scan of thorax & upper abdomen: Tumor left upper lobe ( ~ 3.5 cm) No enlarged mediastinal lymph nodes Normal liver and adrenal glands
      • Bronchoscopy: Not done
    •  
    •  
    • Case Discussion Advanced NSCLC
      • 62-y old male smoker
      • ECOG 1
      • Lung cancer suspected
        • Single brain lesion
        • single lung lesion
        • cT2N0M1
        • clinical stage IV
    • Question
      • Which additional staging procedure(s) surgery would
      • you perform?
      • PET Scan
      • 2) Bone scan
      • Both PET & bone scan
      • Other(s)
      • None
    • Question
      • Which of the following therapies would you recommend
      • as initial therapy for this patient with NSCLC stage IV ?
      • 1) Surgical resection of cerebral metastasis
      • 2) Stereotactic radiosurgery of brain metastasis +/-
      • whole-brain radiotherapy
      • 3) Palliative chemotherapy
    • Case Discussion Advanced NSCLC
      • Dexamethasone
      • Resection of cerebral metastasis as initial therapy
        • March 20, 2001
        • Severe symptoms required rapid relief
        • Squamous cell carcinoma plus large cell carcinoma with neuroendocrine features, compatible with NSCLC
      • Rapid postoperative recovery
        • Nausea & headache disappeared
      • Postoperative whole-brain radiotherapy
        • 30 Gy (May – June 2001)
    • Brain metastasis
      • Frequent in lung cancer
        • Synchronous
        • Metachronous
      • Therapy
        • Surgery
        • Stereotactic radiosurgery
        • Whole-brain radiotherapy
        • Disease status outside of the brain must be considered
    • Therapy of brain metastasis Peacock KH & Lesser GJ. Curr Treat Options Oncol 2006, 7, 479
      • Surgery
        • Single metastasis >3.5 cm
        • Immediate tumor relief necessary
        • Pathological diagnosis required
        • Small tumors with minimal edema & surgically accessible
      • Stereotactic radiosurgery
        • Metastasis <3.5 cm in surgically inaccessible areas
        • Patients not suited fur surgery
        • Small tumors with minimal edema (even when surgically accessible)
    • Stereotactic radiosurgery plus/minus whole-brain radiotherapy Aoyama H et al. JAMA 2006, 295, 2483
      • 142 patients, 1 - 4 metastases (< 3 cm)
      • SRS SRS+WBRT p value
      • Os median 8 mo 7.5 0.4
      • 1-year 28% 38%
      • Brain relapse 76% 47% <0.001
      • Salvage therapy brain ↑
      • WBRT decreases brain relapse rate but does not improve survival
    • Brain metastasis
      • Metachronous
        • Better prognosis than synchronous lesions (33 vs. 9 months from time of diagnosis of NSCLC, p=0.001) but no difference from time of metastasis (12 vs. 8 months, p=0.5) Flannery TW et al. Lung Cancer 2003, 42, 327
        • Surgical resection + whole brain radiotherapy Patchell RA et al. NEJM 1990, 322, 494
      • Synchronous
        • Resection of brain metastasis + whole-brain radiotherapy Billing PS et al. J Thor Cardiovasc Surg 2001, 122, 548
        • Surgical resection of primary tumor ?
    • Question
      • Which of the following therapies would you recommend for
      • this patient after resection of brain metastasis
      • Resection of the primary tumor
      • Resection of the primary tumor followed by systemic chemotherapy
      • Systemic chemotherapy
      • None
    • Case Discussion Advanced NSCLC
      • 62-y old male smoker
      • Surgery of primary tumor: Lobectomy left upper lobe + mediastinal lymphadenectomy (20.4.2001) complete tumor resection
      • Final diagnosis: NSCLC (squamous cell + large cell carcinoma) pT2pN0M1 pathological stage IV complete tumor resection
    • Question
      • Which treatment would you recommend for this patient after
      • resection of the brain metastasis (plus whole-brain
      • radiotherapy) and after resection of the primary tumor
      • No further treatment
      • Systemic chemotherapy
    • Question
      • Which of the following protocols would you use for
      • systemic chemotherapy in this patient with good performance
      • status and normal organ functions?
      • 1) Cisplatin-based doublet
      • 2) Carboplatin-based doublet
      • 3) Non-platinum-based doublet
      • 4) Other
    • Case Discussion Advanced NSCLC
      • Cisplatin/vinorelbine, 4 cycles
        • July - October 2001
      • Regular follow-up
        • No further smoking
        • CT scans thorax plus upper abdomen & MRI of the brain
      • Patient alive 6 years after initial diagnosis
        • Last follow-up on Jan 24, 2007
    • Unresectable NSCLC: Follow-up ASCO guidelines Pfister DG et al. JCO 2004, 22, 3330
      • History & physical examination
        • every 3 months during first 2 years
        • every 6 months thereafter through year 5
        • yearly thereafter
      • Chest radiographs
        • Only in symptomatic patients
      • MRI brain
        • Only in symptomatic patients
      • Smoking cessation
    • Case Discussion Advanced NSCLC
      • Case 2:
      • 43-year old female smoker
      • NSCLC IB (1999): lobectomy right upper lobe adjuvant chemotherapy (IALT)
      • 2 metachronous brain lesions (June 2000): stereotactic radiosurgery of both lesions plus whole-brain radiotherapy
      • Continuous clinical remission in 2007
    • Case Discussion Advanced NSCLC
      • Case 3:
      • 53-year old male smoker
      • NSCLC IV (2005) with single brain metastasis: surgical resection + whole-brain radiotherapy lobectomy systemic chemotherapy
      • Brain relapse (June 2006): stereotactic radiosurgery
      • Currently stable disease
    • Patient Case Discussion Advanced NSCLC Summary
      • Brain metastases are frequent in lung cancer (synchronous, metachronous)
      • Surgery, stereotactic radiosurgery, whole-brain radiotherapy
      • Resection of single brain metastasis and primary tumor can result in long-term survival in patients
        • with good performance status and
        • absence of mediastinal lymph node involvement
      • Resection or radiosurgery (+/- whole-brain radiotherapy) of metachronous single metastasis can also result in long-term survival
      • Not all of the treatment decisions were based on randomized trials
    •  
    •  
    • Question
      • Which therapy would you recommend for this patient with
      • completely resected NSCLC stage IV ?
      • 1) No further therapy
      • 2) Adjuvant cranial irradiation
      • 3) Chemotherapy
      • 4) Chemotherapy and radiotherapy
    • Case study NSCLC
      • Brain metastasis frequent in patients with NSCLC
      • Patients with single brain metastasis lesion and single lung lesion benefit from surgical resection of both lesions
      • Postoperative cranial irradiation & systemic chemotherapy
    • Surgery in NSCLC IV
      • Resection of single cerebral metastasis
      • Resection of lung metastasis
        • Single lung metastasis rare at initial diagnosis
        • Staging
        • Secondary primary
      • Resection of single bone lesion
        • Palliative
      • Resection of adrenal gland metastasis ??
      • Resection of liver metastasis
        • Single lesion is rare
        • Far advanced disease